Regional Approaches to NTD Control in the Americas

Transcription

1 Regional Approaches to NTD Control in the Americas Steven K. Ault Parasitic and Neglected Diseases Program Area of Health Surveillance and Disease Control and Prevention PAHO/WHO Workshop The Causes and Impacts of Neglected Tropical and Zoonotic Diseases IOM Board of Global Health, Forum on Microbial Threats 22 September

2 Neglected Tropical Diseases in Latin America and the Caribbean At least 180 million below poverty line in LAC NTDs disproportionately affect the poor, marginalized, indigenous and ethnic minorities NTDs contribute to perpetuate the Poverty Cycle Social determinants of health do impact the NTDs Water, sanitation, housing, poverty, education, conflict Some NTDs as a historical legacy of slavery: onchocerciasis, lymphatic filariasis, schistosomiasis. Ethical and moral imperative to eliminate NTDs and 2 help address the Unfinished Agenda of Health in LAC

3 Neglected Tropical Diseases: General Impacts Acute and Chronic Diseases with Life-cycle Impacts, Disabling Children and Women Reduce school attendance, attention in class, and test scores Adversely affect children's physical and cognitive development Adversely affect pregnancy outcome, birth weight, neonatal survival Adults Reduce labor productivity Reduce income-earning capacity Create social stigma: leprosy, filariasis, leishmaniasis Incapacity and Premature death 3

4 Elimination of Neglected Diseases in Latin America and in the Caribbean PAHO Resolution CD49 R.19 (October 2009) for the Elimination of Neglected Diseases and other infections related to poverty Presentation of: Background, objective, concept, classification Examples of disease-specific epidemiological data, goals, strategies Opportunities for integrating actions, overlapping, framework and common approaches, current tasks 4

5 Chagas Epidemiological parameters Background Examples of success in the LAC Region Elimination of smallpox, poliomyelitis, measles Interruption of onchocerciasis transmission in 7 out of 13 foci Reduction in the vector-borne domestic transmission and blood transfusional transmission of Chagas disease (below, left) 90% reduction in the number of cases of human rabies transmitted by dogs (below, right) Annual deaths >45,000 12,500 Human cases of infection 30 million 15 million New cases per year 700,000 41,200 At-risk population 100 million 28 million 5

6 PAHO s Epidemiological Profiles of Neglected Diseases of Poverty in Latin America and the Caribbean 10 diseases in 14 countries (1 st admin level mapping) Focus on identifying strategies, collecting epidemiological data on presence and prevalence, and Mapping hot spots of disease overlap Published 2009 Find at

7 PAHO Resolution CD49 R.19 Member States committed in 2009 to: Objective: Eliminate or reduce neglected diseases and other infections related to poverty (NIDs) for which tools exist, to levels such that these diseases are no longer considered public health problems - by Review existing plans or develop new national plans to control or eliminate these diseases

8 Elimination: Concepts Reduction to zero of the incidence of a given disease in a defined geographic area as a result of deliberate efforts; requires continued surveillance and interventions. Elimination as a public health problem: Drastic reduction of the burden of disease to a certain level considered as acceptable given the current available tools and the Region s health situation. This level should be such that it does not constrain social productivity nor community development. Specific goals for each disease are established. 8

9 Classification of NIDs and other poverty- related infections Group 1: Diseases targeted for elimination Group 2: Diseases whose burden can be drastically reduced with available tools Others: Diseases for which the burden of the disease needs to be further assessed, tools need to be developed, and methods and strategies for achieving cost-effective control need to be established. 9

10 Group 1: Elimination Targets Lymphatic filariasis Onchocerciasis Trachoma Chagas disease* Malaria** Human rabies transmitted by dogs Plague Leprosy Neonatal tetanus Congenital syphilis Availability of costeffective strategies and tools Evidence of feasibility in other countries or areas in Latin America and the Caribbean Global or regional mandates to reach elimination 10

11 Lymphatic Filariasis Presence at subnational level,,

12 Onchocerciasis Presence at the first subnational level, LAC,

13 Onchocerciasis: Progress towards the elimination of ocular morbidity and interruption of transmission (02/2010) Focus Has blindness been eliminated? Has ocular morbidity dissappeared? Transmission status Santa Rosa, GU Yes Yes Interrupted in 2006 Lopez de Micay, CO Yes Yes Interrupted in 2007 Escuintla, GU Yes Yes Interrupted in 2007 North Chiapas, MX Yes Yes Interrupted in 2007 Huehuetenango, GU Yes Yes Interrupted in 2008 Oaxaca, MX Yes Yes Interrupted in 2008 Esmeraldas, EC Yes Yes Interrupted in 2007 Interrupted in 2009 South Chiapas, MX Yes Yes Suspected interrupted Central, GU Yes Yes Suspected Interrupted Northcentral, VZ Yes No (1.6%) Suspected Interrupted Northeast, VZ Yes No (4%) Ongoing Amazonas, BR Yes No (6.5%) Ongoing South, VZ Yes No (16.8%) Ongoing

14 Trachoma Presence of at the first sub-national level, LAC,

15 Group 2: Drastic reduction of disease burden Schistosomiasis (S. mansoni) Persistence of areas or sites with a very high prevalence Soil-transmitted helminths Ascaris, Trichuris, hookworms Limited knowledge of epidemiological situation 15

16 Soil-transmitted helminths Prevalence according to available studies,,

17 Soil-transmitted helminths: : How are we doing? Pre-SAC and SAC coverage deworming, AMRO all countries, (Estimate of all Pre-SAC and SAC population) % 90.00% Percentages 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Mexico's data missing Pre-SAC AMRO Region all countries 12.64% 10.90% 1.89% 2.13% 10.53% SAC AMRO Region all countries 34.76% 23.39% 6.67% 5.46% 30.75% SAC = School-age Children AMRO = Americas Region

18 Soil-transmitted helminths: : How are we doing? With Mexico s data added SAC = School-age Children AMRO = Americas Region

19 Schistosomiasis Presence at subnational level,,

20 Diseases for which new strategies & tools are needed for sustainable control Cysticercosis/Taeniasis Leishmaniasis Echinococcosis (Hydatid disease) Food-borne trematodiasis Certain other parasitic zoonoses 20

21 What are we doing ? 2010? NIDs in general: Signed PAHO Resolution CD49.R19: Elimination of NIDs and other poverty-related infections (2009) Epidemiological profiles of 12 NIDs, PAHO (2009) Analysis of progress, priorities and lines of action for five NIDs in LAC (draft 2010) NID Trust Fund in progress: Sabin Vaccine Institute/GNNTD, IADB, PAHO as partners. Fund in IDB. Demo projects in process: PAHO, IADB, Sabin/GNNTD Chiapas, Mexico: developing operational plan, from PoA Recife, Brazil: draft of integrated plan of action (PoA): Leprosy, lymphatic filariasis, schistosomiasis, STH NID Plans of Action (PoA): in process GUY, HON, SUR. Mapping ongoing: Direct mapping projects in several key countries Disease Mapping and Modeling for Neglected and Other Poverty-Related Diseases in Latin America and the Caribbean 3 countries. Forecasting areas, prevalence. Social determinants of health and NIDs in 2 communities, Yucatan, MEX.

22 5 NTDs

23 Neglected Infectious Diseases in Latin America and the Caribbean (Towards Elimination) DISEASE FOCI POPULATION AT RISK Onchocerciasis 13 Foci located in Brazil, Colombia, Ecuador, Guatemala, Mexico and Venezuela Schistosomiasis Foci in 4 countries: Brazil, Venezuela, Suriname and Saint Lucia. Suspected transmission in Dominican Republic POPULATION INFECTED/ELIGIBLE FOR TREATMENT 1 DEC: Diethylcarbamazine, 2 Mexico and Guatemala under revision or in progress mapping to define prevalence value, Children, SAC: School Age Children, 5 MDA: Mass Drug Administration. DRUGS AND FREQUENCY 542, ,253 Ivermectin Twice per year 25,000,000 7,127,425 Praziquantel Once or twice per year TREATMENT COVERAGE 2009 >=85% in all foci Brazil 83% cases treated of cases detected; Guyana 23.4% coverage; Suriname 21 cases treated; Saint Lucia no data available STATUS Transmission interrupted in 7 foci: 2 in Mexico, 3 in Guatemala, 1 in Colombia, 1 in Ecuador To implement preventive chemotherapy for at least 75% of SAC that live in atrisk areas; and improvements of excreta disposal systems and access to drinking water, education 3 SAFE: Surgery, antibiotic, face cleanliness and environmental improvement, REGIONAL TARGETS (Resolution PAHO CD49.R19) To eliminate ocular morbidity (Resolution PAHO CD48/10) To interrupt transmission (Resolution PAHO CD48/10) To reduce prevalence and parasite load in high transmission areas to less than 10% prevalence as measured by quantitative egg counts. 4 Pre-SAC: Pre-school Age Parasitic and Neglected Disease Program, Pan American Health Organization/WHO

24 Neglected Infectious Diseases in Latin America and the Caribbean (Towards Elimination) DISEASE FOCI POPULATIO N AT RISK Lymphatic filariasis Foci in 4 countries: Brazil, Dominican Republic, Haiti and Guyana Trachoma Foci in 3 countries: Brazil, Guatemala and Mexico Soiltransmitted Helminthiasis -STH All countries 13,000,000 Pre-SAC 33,000,000 SAC 4 POPULATION INFECTED/ELIGIBLE DRUGS AND FREQUENCY FOR TREATMENT 9,000,000 3,714,442 DEC+Albendazole 1 50,000,000 Brazil has detected nearly 7,000 cases 2 13,000,000 Pre-SAC 33,000,000 SAC Once per year Azithromycin Once per year Albendazole or mebendazole Once or twice per year 1 DEC: Diethylcarbamazine, 2 Mexico and Guatemala under revision or in progress mapping to define prevalence value, Children, SAC: School Age Children, 5 MDA: Mass Drug Administration. Parasitic and Neglected Disease Program, Pan American Health Organization/WHO TREATMENT COVERAGE 2009 Haiti 3 million of people treated; Brazil 177,000; Guyana 129,189 No data available 4,800,000 Pre-SAC 37,400,000 SAC STATUS Trinidad & Tobago, Suriname and Costa Rica have interrupted transmission: waiting for certification/verifica tion The SAFE strategy in progress 3 Regular administration of preventive chemotherapy/(md A) 5 for at least 75% of SAC at risk 3 SAFE: Surgery, antibiotic, face cleanliness and environmental improvement, REGIONAL TARGETS (Resolution PAHO CD49.R19) To eliminate the disease as a public health problem (less than 1% prevalence of microfilaria in adults in sentinel sites and spotcheck sites in the area). -Interrupt its transmission (no children between ages 2 and 4 are antigen positive). To prevent and control disability To eliminate new cases of blindness caused by trachoma (reduction in the prevalence of trachomatous trichiasis to less than 1 case per 1,000 (general population) and reduction in the prevalence of follicular or inflammatory trachoma (FT and IT) to less than 5% in children aged 1-9 years). To reduce prevalence among school-age children in high risk areas (prevalence >50%) to less than <20% prevalence as measured by quantitative egg count 4 Pre-SAC: Pre-school Age

25 Group classification of LAC countries to address technical cooperation for control or elimination of onchocerciasis, schistosomiasis, lymphatic filariasis, trachoma and soil-transmitted helminths 1 GROUP POPULATION AT RISK % of Pre-SAC and 67.4% of SAC at risk for STH of total in LAC 421,000 for onchocerciasis (Targeted for elimination) 25 million for schistosomiasis (Targeted for elimination in Saint Lucia) 50 million for trachoma (Targeted for elimination) More than 9 million for lymphatic filariasis (Targeted for elimination) % of PreSAC and 26.1% of SAC at risk for STH of total in LAC 115,070 for onchocerciasis A focus of schistosomiasis 3 5.4% of PreSAC and SAC at risk for STH of total in LAC % of PreSAC and 1.1% of SAC at risk for STH of total in LAC *Bolivia is included on group 1, but has border in The Chaco area 1 More information on Preliminary document: Analysis of progress, priorities and lines of action for control and elimination of Neglected Diseases in Latin America and the Caribbean, Specific NIDs information on Contact Dr. Steven Ault aultstev@paho.org Consult our Web site or APPROACH OF TECHNICAL COOPERATION TO NIDs Countries that need technical cooperation to fully develop integrated, inter-programmatic and inter-sectoral plans to combat NIDs. Countries that need technical cooperation to improve interprogrammatic and inter-sectoral coordination and include STH into NIDs integrated actions. Countries that need technical cooperation to focus activities for NIDs at local level and rural areas Countries that need technical cooperation on monitoring and evaluation COUNTRIES Bolivia, Brazil, Dominican Republic, Ecuador, Guatemala, Guyana, Haiti, Mexico, Peru, Saint Lucia and Suriname (N = 11) Colombia, El Salvador, Honduras, Belize, Panama and Venezuela Nicaragua Argentina, Paraguay, Bolivia*: The Chaco area Antigua and Barbuda, Bahamas, Barbados, Chile, Costa Rica, Cuba, Dominica, Granada, Jamaica, Trinidad and Tobago, Uruguay, Saint Kitts and Nevis and Saint Vincent and Grenadines 1 Parasitic and Neglected Disease Program, Pan American Health Organization/WHO

26 Opportunities for integration Overlapping of diseases Principles and common approaches Tasks ahead 26

27 Overlapping of six neglected infectious diseases 27

28 Overlapping of diseases: Opportunities for integrated action 275 administrative units at first subnational level in 14 countries,, 6 selected NIDs 3 units with presence of 4 of 6 selected diseases: Maranhão, Pernambuco and Sergipe (Brazil) STH, schistosomiasis, onchocerciasis, lymphatic filariasis, trachoma, human rabies transmitted by dogs 12 units with presence of 3 of 6 diseases The majority in Haiti, followed by Brazil and Guatemala 41 units with presence of 2 of 6 diseases Of the 580 million inhabitants of LAC, 241 million live in units with the presence of at least one of these diseases 28

29 Principles for integrating actions Available plans, guidelines and tools Evidence-based decisions Reduction of inequalities in health Primary health care system Community participation Gender and ethnicity Interprogrammatic and intersectoral interventions to address the social determinants of health Cooperation between countries Global partnerships in the fight against neglected infectious diseases 29

30 Approaches for integrating actions Common Interventions Screening, Drug treatment/mass Drug Administration Morbidity (case) management (LF, leprosy/hansens) Integrated Vector Management Water Supply, Sanitation, Hygiene, Education (WASHED) Education and School Health for deworming Vitamin A + Deworming Medicine Distribution Other Micronutrients (Fe, I, Zn, multi-vitamin) + Deworming Food vouchers, complementary nutrition to combat undernutrition + Food Security Programs to Reduce Undernutrition and Anemia Integrated Population, Health and Environment Programs Agroforesty, home gardens, aquaculture, beekeeping Primary environmental care 30

31 Approaches for integrating actions Common Interventions Screening, Drug treatment/mass Drug Administration Morbidity (case) management (LF, leprosy) Integrated Vector Management Water Supply, Sanitation, Hygiene, Education (WASHED) Education and School Health for deworming Vitamin A + Deworming Medicine Distribution Other Micronutrients (Fe, I, Zn, multi-vitamin) + Deworming Food vouchers, complementary nutrition + deworming(to combat undernutrition and anemia) Integrated Population, Health and Environment Programs Agroforesty, home gardens, aquaculture, beekeeping Primary environmental care 31

32 Approaches for integrating actions Common Delivery Platforms (MoH programs) for Neglected Diseases Services: Primary Health Care Vector Control Nutrition/Micronutrients Immunizations (children, adolescents, pregnant women) Maternal-child Health, Family Health and Wellness Skin disease clinics, Diabetes/chronic diseases clinics Food Security, Food Safety Healthy Schools, Healthy Cities Multi-disease Approach: two or more overlapping NTDs (i.e., NTD hot spots ); plus malaria, dengue 32

33 Safe water in schools and houses Ventilated Improved Pit (VIP) latrines Improvement of the house and its surroundings Control and recycling of solid waste Use of shoes Health Education and social mobilization Interventions (e.g., COMBI, others) Microcredit Social and environmental services to control or eliminate the determinants of diseases (diseasespecific). Identification of minimum packages currently used Integrated plans of action (POAs) Elimination and control of NIDs in LAC Identifying stakeholders: International National Local Mapping of disease and their overlapping ( hot spots ) Health sector Other sectors: Education, Environment, Water and sanitation, Community leaders, Infrastructure, Poverty reduction, Community development, Agriculture and livestock, Nutrition, Gender Human rights/ indigenous peoples rights Nutrition Development of minimum packages for the future Whom shall the services be provided to? Where? How? When (frequency)? Quality? Identification of common platforms for delivery of services and drugs (for MDA) Delivery of health services Mapping key social determinants of health (water, sanitation, housing, malnutrition, unemployment) Information and planning Delivery of services

34 Tasks Ahead to Combat Neglected Infectious Diseases in LAC Collaboration of partners is key: PAHO/WHO with endemic countries, GAELF, IADB, Sabin/Global Network for NTDs, CDC, Carter Center, OEPA, TFGH, CWW, ITI, pharma & other partners to: Develop evidence-based guidelines and demonstration projects for integrated control/elimination. Develop models and interventions to address social determinants. Strengthen, scale-up and intensify existing programs of control and elimination through technical cooperation. Develop integrated national plans of action (POAs). Plan for WHO certification of elimination of diseases in countries: onchocerciasis, lymphatic filariasis, trachoma. Get IADB/PAHO Regional Trust Fund for NIDs open for business. Address research gaps. 34

35 Conclusions NIDs can be eliminated in the Americas oncho LF (and LF+Malaria in Hispaniola) trachoma schisto in Suriname and St. Lucia Chagas (certain vectors). Keys include mapping, integrated national action plans, using existing tools, financing and partnerships, M&E It s s an ethical and moral imperative! 35

36 Thank you! Keyword: Neglected Diseases